Looking after our teeth and gums is important not only for the sake of our mouths but the rest of our bodies too. Steve Titmarsh explains…

Links between gum disease and chronic diseases like diabetes and heart conditions suggest that regular toothbrushing is more important than ever. Growing evidence suggests that oral health, in particular the state of the oral microbiota (viruses, protozoans, fungi and other organisms that naturally inhabit the oral cavity) is intrinsically linked with health in general.¹ Indeed, an imbalance in the micro-organisms in the mouth can cause oral infections such as dental caries and gum disease (periodontitis).

Equally these mouth infections can upset the balance of the microbiota. Without a good oral hygiene regime bacteria can grow to levels that can result in infection and associated inflammation, with tooth decay and gum disease as a result.

Local inflammation in the mouth is thought to be linked to disease elsewhere in the body as well, perhaps through circulation of micro-organisms from the mouth, or pathogenic constituents of these organisms, to the rest of the body via the bloodstream.²

The National Institute for Health and Care Excellence says that oral health can impact on people’s ability to eat, speak and socialise, and it can lead to absences from school and work and it can affect children’s ability to learn, thrive and develop.³

Diabetes and gum disease

People with diabetes, and particularly individuals whose diabetes is not well controlled, are at an increased risk of periodontal (gum) disease.⁴ Also, people with diabetes are more likely to have periodontitis, and the two conditions affect each other. Indeed, there is growing evidence to suggest that periodontitis is a risk factor for complications of diabetes such as cardiovascular disease and ischaemic stroke.⁵

Respiratory disease and oral health

There are a number of studies that suggest oral hygiene is linked to acute and chronic respiratory diseases such as asthma, chronic obstructive pulmonary disease and pneumonia. It may be that aspiration of elements of the oral microbiota such as inflammatory proteins associated with periodontitis or bacteria themselves may be involved in respiratory disease. Whether there is a cause and effect is still not known but inflammation is known to exist in diseases such as asthma and COPD.⁶ And research has shown that brushing teeth reduces the incidence, duration and death from pneumonia.⁷

Cardiovascular disease and tooth decay

A number of links between oral health and cardiovascular disease have been found in studies. For example, people who have had a stroke have been found to have significantly more caries than healthy people. And tooth loss seems to be associated with a higher risk of coronary heart disease and death. However, evidence of cause and effect between periodontal disease or caries  and heart disease has not been established.⁸

Pregnancy

Hormonal changes during pregnancy mean women are at greater risk of gum disease. For example, so called pregnancy gingivitis affects about 40% of pregnant women. It usually begins at about the second month of pregnancy, peaks during the eight month and spontaneously resolves after birth.⁹

Tooth decay can increase during pregnancy. It may be due to vomiting, which can affect oral hygiene and erode tooth enamel due to higher levels of acid in the mouth; some women experience an increased desire for foods containing carbohydrate, which can also adversely affect oral health. Eating a balanced diet including fruits, vegetables, cereal, milk, dairy products, meat, fish and eggs that are rich for A, C, D vitamins, calcium and phosphorus, and avoiding sugar as much as possible is advisable. Dried fruit should be avoided.⁹

Advice pharmacy teams can offer

Regular tooth brushing with a fluoride toothpaste, at least twice a day (last thing before bed and at another time during the day) helps prevent, stop and control caries. It also helps keep gums healthy. People with established gum disease (periodontitis) may need to brush for longer than the recommended two minutes and adults should clean between teeth preferably using interdental brushes.¹⁰

For most people a toothbrush with a small head and medium texture bristles will be suitable.¹⁰

Government guidance recommends that for people, particularly those who are children with chronic illness, people with special needs or vulnerable older adults, on long-term medication that contain sugars (liquid, chewable or soluble formulations) should be offered sugar-free formulations wherever possible.¹¹ 

Some medicines may affect gum health. For example, antidepressants may cause dry mouth and calcium channel blockers may cause enlargement of the gums.

Regular check-ups by a dentist are important for all.¹¹ The interval between check-ups will vary from person to person. People who are at greater risk of caries and gum disease, including those with disabilities should see their dentist more regularly and some may benefit from application of dental varnish twice a year.¹²

It is important that children form good oral hygiene habits early in life to help avoid tooth decay. A number of strategies can help:¹³

• Cut down on free sugars found in cakes, biscuits, chocolates, processed foods (such as jarred sauces, jams and breakfast cereals) and some flavoured yoghurts; they are found in natural products such as honey, fruit juices and purees and smoothies. Whole fruit, vegetables, plain unflavoured milk and yoghurt and water do not contain free sugars. In terms of oral health, water and milk are the only safe drinks to give children.
• Young children should not be given fruit juices and smoothies every day.
• Sugar-containing food and drink should be limited to mealtimes because the more frequently teeth are in contact with sugar the more likely tooth decay becomes.
• Babies should be given only breast milk, formula milk or water (boiled and cooled)
• Children should start brushing their teeth as soon as they start to show.

Box: Effective toothbrushing¹³

• Use a fluoride toothpaste containing at least 1000 parts per million (ppm) of fluoride
• Use a smear of toothpaste for children under 3 years old, and a pea-sized amount for those aged 3 to 6 years
• Brush in circles for around 2 minutes, making sure to cover the whole of each tooth
• Brush twice a day, including once just before bed, so the fluoride can keep working while children sleep
• Children should spit, not rinse, after brushing to stop the fluoride being washing away
• Adults should help children to brush their teeth until they are 7 years old to make sure they brush correctly

Resources

British Dental Association – resources for children and adults: https://bda.org/library/oral-hygiene

NHS England – Children’s oral health advice: www.e-lfh.org.uk/programmes/childrens-oral-health

Public Health England – Oral health toolkit for adults in care homes: www.gov.uk/government/publications/adult-oral-health-in-care-homes-toolkit/oral-health-toolkit-for-adults-in-care-homes

Department of Health and Social Care – Delivering better oral health: an evidence-based toolkit for prevention: www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-prevention

Office for Health Improvement and Disparities – Adult oral health: applying All Our Health: www.gov.uk/government/publications/adult-oral-health-applying-all-our-health/adult-oral-health-applying-all-our-health

British Society of Paediatric Dentistry. Smiles for life – www.bspd.co.uk/Kidsvids

NHS.UK. Looking after your baby's teeth – www.nhs.uk/conditions/baby/babys-development/teething/looking-after-your-babys-teeth/

UK Government guidance – Safeguarding and welfare. Oral health: https://help-for-early-years-providers.education.gov.uk/safeguarding-and-welfare/oral-health

World Health Organization. Oral health: www.who.int/health-topics/oral-health

Scottish dental Clinical Effectiveness Programme – Oral hygiene TIPPS video: www.sdcep.org.uk/published-guidance/periodontal-care/oral-hygiene-tipps-video

References

1. www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/dental/art-20047475; accessed August 2023.
2. Thomas C, Minty M, Vinel A, et al. Oral Microbiota: A Major Player in the Diagnosis of Systemic Diseases. Diagnostics (Basel) 2021;11:1376.
3. National Institute for Health and Care Excellence (NICE). Oral health promotion: general dental practice. NICE guideline [NG30). London: NICE, 2015.
4. Midwood I, Hodge P. Diabetes and gum disease: Does oral health matter? Journal of Diabetes Nursing 2018;22.
5. Borgnakke WS, Poudel P. Diabetes and Oral Health: Summary of Current Scientific Evidence for Why Transdisciplinary Collaboration Is Needed. Front Dent Med 2021;2: 709831.
6. Gaeckle NT, Pragman AA, Pendleton KM, et al. The Oral-Lung Axis: The Impact of Oral Health on Lung Health. Respir Care 2020;65(8):1211–20.
7. Manger D, Walshaw M, Fitzgerald R, et al. Evidence summary: the relationship between oral health and pulmonary disease. Brit Dent J 2017;222:527–33.
8. Dietrich T, Webb I, Stenhouse L, et al. Evidence summary: the relationship between oral and cardiovascular disease. Br Dent J 2017;222(5):381–5.
9. Yenen Z, Ataçağ T. Oral care in pregnancy. J Turk Ger Gynecol Assoc 2019;20(4):264–8.
10. Department of Health and Social Care – Delivering better oral health: an evidence-based toolkit for prevention. Chapter 8: Oral hygiene (www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-prevention/chapter-8-oral-hygiene; accessed August 2023).
11. Department of Health and Social Care – Delivering better oral health: an evidence-based toolkit for prevention. Chapter 4: Dental caries (www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-prevention/chapter-4-dental-caries; accessed August 2023).
12. Department of Health and Social Care – Delivering better oral health: an evidence-based toolkit for prevention. Chapter 2: Summary guidance tables for dental teams (www.gov.uk/government/publications/delivering-better-oral-health-an-evidence-based-toolkit-for-prevention/chapter-2-summary-guidance-tables-for-dental-teams; accessed August 2023).
13. GOV.UK. Safeguarding and welfare: Oral health (https://help-for-early-years-providers.education.gov.uk/safeguarding-and-welfare/oral-health; accessed July 2023).